Provider Demographics
NPI:1245239292
Name:HUMPHREY, ROGER LEA (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LEA
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 NEW HARTFORD RD
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1320
Mailing Address - Country:US
Mailing Address - Phone:270-683-3720
Mailing Address - Fax:270-686-7331
Practice Address - Street 1:2801 NEW HARTFORD RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1320
Practice Address - Country:US
Practice Address - Phone:270-683-3720
Practice Address - Fax:270-686-7331
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046282A208600000X, 2086S0129X
KY197612086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200132180OtherMOLINA
IN200132180Medicaid
KY611059472OtherDART
KY64197619Medicaid
IN6110594722109OtherCARESOURCE
KY000000048413OtherANTHEM
611059472OtherUMWA
020038275OtherRAILROAD MEDICARE
IN630980GMedicare PIN
KY64197619Medicaid
D33913Medicare UPIN